Must Reads

Patient Safety Weekly Must Reads (February 25, 2017)

This week in #patientsafety, we issued a statement on our position about the need to treat patient ambulation as a key metric. From around the web, ISMP released an updated self assessment for community/ambulatory pharmacy medication safety. We also found figures on opioid-related inpatient stays and emergency department visits by state from 2009-2014, and a dentist’s statement that the industry prescribes opioids “way too quickly”.


Patient Ambulation a Key Metric to Improved Health. PPAHS calls for dialogue at the clinical and governmental levels to identify and codify best practices that will prioritize patient ambulation.

From Around the Web:

ISMP Releases Updated Community/Ambulatory Pharmacy Medication Safety Self Assessment. Community and ambulatory pharmacy settings can now access a newly revised tool that will help them review and improve their medication safety practices.

Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009-2014. This HCUP Statistical Brief presents data from HCUP Fast Stats on the national rate of opioid-related hospital inpatient stays and emergency department (ED) visits from 2005 to 2014.

Opioids unnecessary for dental work, doc says. The American Dental Association recently reported dentistry is responsible for prescribing 12 percent of all instant-release opioids.

Opioid Safety, Patient Safety, Respiratory Compromise

Drawn Curtains, Muted Alarms, And Diverted Attention Lead To Tragedy In The Postanesthesia Care Unit

By Institute for Safe Medication Practices (ISMP)

Editor’s Note: This article first appeared on the ISMP website. It discusses the role that inadequate monitoring and muted alarms played in the recent tragic recent death of a 17-year old following a tonsillectomy. PPAHS has previously discussed deaths of pediatric patients following dental or oral procedures. We welcome your thoughts and comments on this issue.

Problem: Last April, a 17-year-old girl died following an uncomplicated tonsillectomy performed in an outpatient ambulatory surgery center after receiving a dose of IV fentaNYL in the postanesthesia care unit (PACU). The case made headline news again recently when a civil lawsuit filed by the teen’s parents was resolved. While it is too late to reverse the tragic outcome of this case, we call upon all hospitals and outpatient surgery centers to learn from the event and take action to prevent a similar tragedy in your facility. Read More

Opioid Safety, Respiratory Compromise

Was Gary Bougie’s Post-op Gallbladder Surgery Death Preventable?

Fox 9 News recently reported on the death of Gary Bougie following routine gall bladder surgery:

Gary Bougie was two months shy of his 36th birthday when he died nearly two years ago. His family suspects he died from a condition called opioid-induced respiratory depression after going to the hospital for gallbladder surgery and they want to warn other families about how to possibly avoid a tragedy like this

Bougie had just opened his new restaurant when he went to United Hospital for surgery to remove his gallbladder back in April of 2014. He stayed overnight for observation, but his parents say learning the next morning he’d passed away from complications during the night was surreal.

While the medical examiner ruled there was no anatomical cause for Bougie’s death, his family believes the mix of pain meds he was on caused him to fall into such a deep sleep, he stopped breathing. They are suing the hospital. Their attorney says even though nurses checked on Bougie once an hour, they should have used a fingertip sensor that would have alerted them when the level of oxygen in his blood went too low. Read More

Alarm Fatigue, Opioid Safety, Patient Stories, Respiratory Compromise

Perspectives on Opioid Safety and Continuous Electronic Monitoring

by Sean Power

In honor of Patient Safety Awareness Week last week, the Premier Safety Institute gathered experts on opioid safety to participate in a webinar discussion. The panel, moderated by Gina Pugliese, RN, MS, vice president, Premier Safety Institute, Premier Inc., featured several authorities on opioid safety, including: Read More

Opioid Safety, Respiratory Compromise

Does CMS’ Proposed Quality Measure on Patient Monitoring Adequately Address Patient Safety?

by Michael Wong

(This article first appeared in Becker’s Clinical Quality & Infection Control.)

CMS is considering a proposed quality measure that would require “appropriate monitoring of patients receiving PCA [patient-controlled analgesia].” This measure seeks to address the high number of errors that occur with PCA, which unfortunately research shows happens all too frequently. Read More

Opioid Safety, Patient Stories, Respiratory Compromise

Does CMS Proposed Measure for PCA Safety Go Far Enough?

by Michael Wong

(This article is reprinted with the permission of Patient Safety & Quality Healthcare (PSQH).)

This is the question that I have been asking myself ever since Centers for Medicare & Medicaid Services (CMS) recently announced proposed quality measures it is considering for adoption through rule making for the Medicare program. Read More

Alarm Fatigue, Opioid Safety, Respiratory Compromise

10 Reminders to Ensure Safer Use of Patient-Controlled Analgesia

PCA-related device events are three times as likely to result in injury or death. As Tim Ritter (Senior Patient Safety Analyst, Pennsylvania Patient Safety Authority) reminds us, “Over the six-year period from June 2004 to May 2010, data collected by Pennsylvania Patient Safety Authority revealed that there were approximately 4,500 reports associated with PCA pumps. Moreover, U.S. Food and Drug Administration’s (FDA) Manufacturer and User Device Experience (MAUDE) database demonstrates that PCA-related device events are three times as likely to result in injury or death as reports of device events involving general-purpose infusion pumps.” Read More

Opioid Safety, Respiratory Compromise

Hospitals Need to Address PCA Pump Patient Safety: Q&A with ISMP & Pennsylvania Patient Safety Authority

by Michael Wong

Pain control in hospitals using patient-controlled analgesia (PCA) need to be made safer. In this interview with Michael Wong of the Physician-Patient Alliance for Health & Safety (PPAHS), Tim Ritter (Senior Patient Safety Analyst at the Pennsylvania Patient Safety Authority) and Matthew Grissinger (Director, Error Reporting Programs at ISMP) discuss PCA pumps and why reliance on periodic checks by caregivers and pulse oximetry can only catch an adverse event, but not prevent an adverse event from occurring. For patient safety, PPAHS encourages continuous electronic monitoring, including the use of both capnography and pulse oximetry, of all patients using patient-controlled analgesia (PCA). Read More